Considerations in geriatric dermatopathology.

This review provides an overview of considerations in geriatric dermatopathology. The nuances of specimen collection and reporting in this population, including the importance of obtaining adequate tissue, providing detailed clinical information and ethical considerations surrounding specimen collection will be discussed. The histopathologic changes associated with aging and the morphologic features of common lesions related to photoaging are outlined followed by a discussion of common interpretation pitfalls, specifically entities at risk of overinterpretation and those related to hyper- and hypopigmentation. Finally, the recent literature is reviewed regarding special cases and what this implies for future research both in dermatology and dermatopathology.

Vertebral and Basilar Artery Dissection in a Patient With Alport Syndrome.

Basilar artery occlusion (BAO) is a rare cause of stroke associated with significant morbidity and mortality. It is most frequently thromboembolic in nature, but may be caused by vertebral artery dissection. We present a case of BAO in a 36-year-old woman with Alport syndrome. She was treated with emergent thrombectomy via the right vertebral artery with return to baseline neurological status. Her clinical status deteriorated later the same day and she was found to have re-occlusion. Repeat thrombectomy was complicated by persistent re-occlusion requiring 7 passes to achieve reperfusion. Unfortunately, her neurological exam remained poor and she was transitioned to comfort care, expiring on admission day 3. An autopsy demonstrated acute dissection of the left vertebral artery, basilar artery, and bilateral posterior cerebral arteries. Alport syndrome is a type IV collagenopathy most known for causing kidney disease. It may also be associated with vascular fragility as type IV collagen forms a significant component of the vascular basement membrane. There are reports of aortic, coronary, and cervical dissections, but few reports of intracranial dissections in patients with Alport syndrome. While iatrogenic dissection cannot be ruled out, the histological findings in this case are most consistent with spontaneous arterial dissection as the cause of her initial neurologic presentation. This highlights the need for further investigation into the relationship between Alport syndrome and vascular fragility and should alert clinicians to the possibility of intracranial dissection in patients with AS.

Utility of GLI1 RNA Chromogenic in Situ Hybridization in Distinguishing Basal Cell Carcinoma From Histopathologic Mimics.

Basal cell carcinoma (BCC) is the most common human malignancy and is a leading cause of nonmelanoma skin cancer-related morbidity. BCC has several histologic mimics which may have treatment and prognostic implications. Furthermore, BCC may show alternative differentiation toward a variety of cutaneous structures. The vast majority of BCCs harbor mutations in the hedgehog signaling pathway, resulting in increased expression of the GLI family of transcription factors. GLI1 immunohistochemistry has been shown to discriminate between several tumor types but demonstrates high background signal and lack of specificity. In this study, we evaluated the utility of GLI1 RNA chromogenic in situ hybridization (CISH) as a novel method of distinguishing between BCC and other epithelial neoplasms. Expression of GLI1 by RNA CISH was retrospectively evaluated in a total of 220 cases, including 60 BCCs, 37 squamous cell carcinomas (SCCs) including conventional, basaloid, and human papillomavirus infection (HPV)-associated tumors, 16 sebaceous neoplasms, 10 Merkel cell carcinomas, 58 benign follicular tumors, and 39 ductal tumors. The threshold for positivity was determined to be greater than or equal to 3 GLI1 signals in at least 50% of tumor cells. Positive GLI1 expression was identified in 57/60 BCCs, including metastatic BCC, collision lesions with SCC, and BCCs with squamous, ductal, or clear cell differentiation or with other unusual features compared to 1/37 SCCs, 0/11 sebaceous carcinomas, 0/5 sebaceomas, 1/10 Merkel cell carcinomas, 0/39 ductal tumors, and 28/58 follicular tumors. With careful evaluation, GLI1 RNA CISH is highly sensitive (95%) and specific (98%) in distinguishing between BCC and nonfollicular epithelial neoplasms. However, GLI1 CISH is not specific for distinguishing BCC from most benign follicular tumors. Overall, detection of GLI1 RNA by CISH may be a useful tool for precise classification of histologically challenging basaloid tumors, particularly in the setting of small biopsy specimens, metaplastic differentiation, or metastatic disease.

Detection of antibody-coated Mucor in skin biopsy by direct immunofluorescence.

Cutaneous mucormycosis may be caused by direct inoculation or hematogenous spread of mucormycetes in immunocompromised patients. Skin biopsy is characterized by a deep fungal infection with frequent angioinvasion. The fungal hyphae can usually be identified on H&E stain. We report a case of cutaneous angioinvasive mucormycosis in which the fungi were also visualized on direct immunofluorescence. A 57-year-old patient with relapsed myelodysplastic syndrome status-post allogeneic hematopoietic cell transplant, diabetes mellitus, and graft-versus-host disease presented with painful, palpable, dark-red to violaceous retiform purpuric plaques. Light microscopy of punch biopsy revealed numerous broad, ribbon-like, pauci-septate hyphae in the dermis with angioinvasion, consistent with mucormycosis. Direct immunofluorescence performed on a concurrent biopsy to exclude immune complex vasculitis showed smooth IgG, IgA (weak), IgM (faint), and C3 deposition on the hyphal structures, compatible with antibody-coated fungi. Tissue culture subsequently confirmed Mucor species. Although mucormycosis was readily diagnosable on routine light microscopy in this case, recognition of the unique phenomenon of antibody-coated fungi can be crucial when the invasive fungi are sparse or only present in the direct immunofluorescence specimen.

Seat belt use among patients in motor vehicle collisions: Clinical and demographic factors.

OBJECTIVE: Proper use of automobile seat belt in a motor vehicle crash is associated with reduced morbidity and mortality, shorter hospital stays, reduced resource utilization, and fewer missed work days. Seatbelt compliance nationwide is 86%. This study was undertaken to identify factors associated with noncompliance with seatbelt use among admitted patients following a motor vehicle crash. METHODS: This study was a retrospective analysis of motor vehicle crashes at an Urban Level 1 Trauma Center. Eligible subjects included patients age 18 and over, who were admitted by the Trauma Service following a motor vehicle crash from January to December 2017. RESULTS: Among 766 participants, the overall rate of seatbelt noncompliance was 32% (N = 245). Some participants met the legal limit of intoxication (80 mg/dl) (N = 119 patients; 22%). Drug use was high among this population, including THC (30%), opiates (29%), benzodiazepines (24%), cocaine (10%), and methamphetamine (10%). Patients who did not wear seat belts were more likely to be male (62.4% no seat belt vs. 51.8% seat belt), intoxicated (30.5% vs. 17.0%), screen positive for cocaine (18.2% vs. 4.7%), THC (37.7% vs. 24.2%), and methamphetamine (15.6% vs. 5.9%). We did not detect significant differences by seat belt use with respect to ethnicity, mode of arrival, day of week, opiate use, or benzodiazepine use. CONCLUSIONS: In this study, 32% of patients in motor vehicle crashes were not compliant with seat belt use. Noncompliance with seat belt use was higher among patients who were male, younger age, intoxicated, or who had positive screens for cocaine, THC, or methamphetamine.

Diagnostic accuracy of visual urethral mobility exam versus Q-Tip test: a randomized crossover trial.

OBJECTIVE: The objective of the study was to compare the diagnostic accuracy of a visual urethral mobility examination (VUME) with a Q-Tip test in the assessment of urethral hypermobility. STUDY DESIGN: Subjects were randomized to a VUME or Q-Tip test first, followed by the alternate assessment. Outcomes included hypermobile, not hypermobile, or indeterminate. Hypermobility was defined as 30° or greater from the horizontal. Pain perception and test preference were assessed. RESULTS: For the 54 subjects, 61.1% demonstrated hypermobility on VUME vs 72.2% on the Q-Tip test (P = .39). Assessment of hypermobility was correlated between the 2 tools (ρ = 0.47, P = .001). Positive and negative predictive value, sensitivity, and specificity for VUME were 88%, 56%, 78%, and 71%, respectively, with a Q-Tip test as the reference standard. Mean pain score on visual analog scale was 0.72 for VUME and 3.15 for Q-tip test (P < .001). VUME was preferred by 83% of subjects. CONCLUSION: VUME is a diagnostic alternative to the Q-Tip test for the assessment of urethral hypermobility and is preferred by subjects.